Cardiovascular pre-participation screening and risk ...€¦ · ters athlete. R outine physical activity is associated with improved health and well-being and a reduction in adverse

196 bc medical journal vol. 58 no. 4, may 2016 bcmj.org

This article has been peer reviewed.

Barbara N. Morrison, BHK, Hamed Nazzari, MD, PhD, Daniel Lithwick, MHA, Jack Taunton, MD, Saul H. Isserow, MBBCh, Brett Heilbron, MB ChB, Darren E.R. Warburton, PhD

ABSTRACT: Although routine physi-

cal activity is associated with health

benefits, there is also a transient in-

creased risk of adverse cardiovascu-

lar events during vigorous physical

activity. Methods to detect disease

and ensure that athletic pursuits are

safe and appropriate have been pro-

posed. However, for competitive ath-

letes older than 35 years—masters

athletes—debate about the optimal

battery of tests for comprehensive

risk assessment has been consid-

erable. While the use of tools such

as the Physical Activity Readiness

Questionnaire for Everyone is stan-

dard, some agencies recommend

more comprehensive risk assess-

ment processes, and screening pro-

tocols vary widely across the world.

Along with some form of pre-partic-

ipation screening, risk-mitigating

strategies might include educating

masters athletes to exercise safely,

to report new and unusual symp-

toms for evaluation, and to consider

preventive health habits (e.g., moni-

tor blood pressure and lipid levels,

maintain healthy body weight). Other

Cardiovascular pre-participation screening and risk assessment in the masters athlete: International recommendations and a Canadian perspectiveMore evidence is needed to determine the best strategies to mitigate risk of adverse cardiovascular events during exercise for those older than 35.

Ms Morrison is a project and research coor-

dinator for SportsCardiologyBC and is com-

pleting a master’s degree in experimental

medicine at the University of British Co-

lumbia. Dr Nazzari is a resident in internal

medicine at UBC. Mr Lithwick is a project

and research coordinator at SportsCardiolo-

gyBC and has completed a master’s degree

in health administration at UBC. Dr Taunton

is co-founder of SportsCardiologyBC and a

professor in the Division of Sports Medi-

cine at UBC. Dr Isserow is co-founder and

medical director of SportsCardiologyBC

and director of cardiology services at both

strategies might include modifying

exercise for high-risk individuals,

ensuring emergency procedures are

in place, and installing automated

external defibrillators in all sporting

venues. Developing pre-participa-

tion screening and risk assessment

recommendations for Canada’s het-

erogeneous population will require

a better understanding of cardiovas-

cular disease prevalence and more

evidence regarding the effective-

ness of proposed pre-participation

screening procedures for the mas-

ters athlete.

R outine physical activity is associated with improved health and well-being and a

reduction in adverse cardiovascular events and all-cause mortality, while physical inactivity is known to be a risk factor for the development of car-diovascular disease (CVD) and pre-mature mortality.1 Physical inactivity is associated with at least 25 chronic medical conditions.1 However, there is also a transient increased risk of adverse cardiovascular events during vigorous physical activity, especially for masters athletes—those older than 35 years involved in recreational and

UBC Hospital and the Centre for Cardiovas-

cular Health at Vancouver General Hospital.

Dr Heilbron is a cardiologist at SportsCar-

diologyBC and a clinical assistant profes-

sor in the Division of Cardiology at UBC.

Dr Warburton is a founding member of

SportsCardiologyBC and a full professor

in the Experimental Medicine Program at

UBC. He is also director of the Cardiovas-

cular Physiology and Rehabilitation Labora-

tory at UBC and co-director at the Physical

Activity Promotion and Chronic Disease

Prevention Unit at UBC.

197bc medical journal vol. 58 no. 4, may 2016 bcmj.org

Cardiovascular pre-participation screening and risk assessment in the masters athlete

competitive athletics at a high level. Many of these individuals participate in athletic endeavors for a variety of reasons: improved self-image, love of competition, enjoyment of camarade-rie, and stress reduction.

Despite the proven health benefits of exercise, there is also clear evi-dence that an acute bout of exercise transiently increases the risk for po-tentially life-threatening events such as myocardial infarction, aortic dis-section, arrhythmia, sudden cardiac arrest, and sudden cardiac death.2,3 In a recent study of sports-related deaths in the general population age 10 to 75 from 2005 to 2010 in France, researchers found 90% of cases oc-curred during recreational sport. The mean age in the sudden death cases was 46 ±15 years.4 To mitigate risk and ensure activities are safe and ap-propriate in both recreational and competitive athletics, strategies such as pre-participation screening and cardiovascular risk assessment have been proposed.5 When attempting to reduce the risks associated with ex-ercise for masters athletes, there are some unique considerations.

Who is at risk?Sudden cardiac death (SCD) is de-fined as death that occurs unexpected-ly within an hour or less of the onset of symptoms.3 In the masters athlete 35 years and older the primary cause of sudden cardiac death is atheroscler-otic disease, whereas in the athlete younger than 35 years genetic or con-genital cardiovascular abnormalities are predominately responsible.5,6 The common feature of SCD in younger and older athletes is lack of symptoms for any underlying CVD.

The transient risks associated with an acute bout of exercise appear to be the greatest in physically inactive in-dividuals who engage in vigorous-in-tensity activities; that is, exercise that

involves expending 6 METs (meta-bolic equivalent tasks), a measure of more than 21 mL of oxygen per kg per minute.2,3 Moreover, the risk of sudden cardiac death can be attenu-ated greatly with regular activity. For instance, when Siscovick and col-leagues compared the risk of cardiac arrest during exercise and during rest,

they found that the relative risk (RR) during exercise was 5-fold higher in highly active individuals and 56-fold higher in those with the lowest activ-ity levels.2 Albert and colleagues also demonstrated that habitually active men (i.e., those who exercise at least 5 times per week) have a much lower relative risk of sudden cardiac death (RR = 10.9) than men who exercise vigorously less than once a week (RR = 74.1).3 Interestingly, compared to risk during periods of mild or no physical activity, vigorous physical activity transiently increased the risk of sudden cardiac death from a fac-tor of 14 to 45. This risk remained el-evated in even the most active men. Importantly, despite these increased risks the evidence is clear that the lifetime risks for adverse cardiovas-cular-related events are markedly lower in active individuals across the life span.2,3

Current screening recommendationsVarious pre-participation screening and risk stratification tools are cur-rently available. These range from self-administered questionnaires to protocols involving assessment by health care professionals.7,8 These questionnaires and protocols were

developed for use in the general pop-ulation, but have been incorporated into most athletic settings. Leading agencies such as the American Heart Association (AHA), the American College of Sports Medicine (ACSM), and the American Association of Car-diovascular and Pulmonary Rehabili-tation (AACVPR) have developed important screening recommenda-tions for the general population.9 Pre-participation screening and risk strati-fication before the start of an activity program (i.e., physical activity clear-ance) or before exercise testing have significant medicolegal implications and are widely considered standard practice.7,8,10 Recent advances in screening and risk stratification with the use of the Physical Activity Read-iness Questionnaire for Everyone (PAR-Q+) and the electronic Physical Activity Readiness Medical Exami-nation (ePARmed-X+) have greatly

In a recent study of sports-

related deaths in the general

population age 10 to 75 from 2005

to 2010 in France, researchers

found 90% of cases occurred

during recreational sport.



reduced the barriers to physical activi-ty participation for apparently healthy individuals and those with established chronic medical conditions across the lifespan.7,8

Components of screening for athletesOwing to medicolegal requirements, the completion of simple question-naires such as the PAR-Q+ and the AHA/ACSM Health/Fitness Facil-ity Pre-participation Screening Ques-tionnaire is considered standard when working with young competitive and masters athletes.7,8,10 However, many agencies have recommended more comprehensive risk assessment bat-teries. This has led to considerable debate and pre-participation screen-ing recommendations and protocols that vary widely across agencies and countries. For instance, there are clear differences in the pre-participation

screening recommendations of the European Association of Cardiovas-cular Prevention and Rehabilitation (EACPR) and the American Heart Association ( Table ).6,9 The EACPR suggests an individual approach, in which the level of testing required depends on the intended level of physical activity/exercise and the risk determined by self-assessment (i.e., results from the PAR-Q+ or AHA/ACSM questionnaires).9 By contrast, the AHA recommends a selective approach involving a history, physi-cal examination, and resting ECG for all masters athletes, and a maximal exercise treadmill test for masters athletes who are older than 40 (men) or 50 (women) and have one addi-tional cardiovascular risk factor.6 The issue of cardiovascular pre-participa-tion screening has been the topic of discussion in a number of countries, but there have been no contributions

yet from any notable Canadian health organizations.

Cardiovascular risk scoreThe use of cardiovascular risk scores to determine a person’s 10-year risk of CVD has been widely accepted and varies slightly from one country to another. In Europe, the Systematic COronary Risk Evaluation (SCORE) system takes into account age, sex, blood pressure, cholesterol levels, and smoking history.9 An individual is considered high risk if he or she has one of the following: a 10-year risk score higher than 5%, elevated total blood cholesterol (above 8 mmol), elevated LDL cholesterol (above 6 mmol), elevated blood pressure (greater than 180/110 mm Hg), dia-betes with microalbuminuria, family history of premature CVD in first-degree relatives younger than age 50, or a BMI greater than 28. Simi-

Physical activity clearance

• PhysicalActivityReadinessQuestionnaireforEveryone(PAR-Q+)• ElectronicPhysicalActivityReadinessMedicalExamination(ePAR-Q+)• AHA/ACSMHealth/FitnessFacilityPre-participationScreeningQuestionnaire

Pre-participation screening

Individual approach (EuropeanAssociationofCardiovascularProtectionandRehabilitation)

Selective approach (AmericanHeartAssociation)

Eligibility for pre-participation screening

• Alladult/seniornonprofessionalathletesengagedinvigorousactivity

• Athletesengagedinmoderateactivitywhosephysicalactivityclearanceassessment(i.e.,resultsfromPAR-Q+orAHA/ACSMquestionnaires)hasidentifiedrisk

• Allmastersathletes>40years

Pre-participation screening components

• History• Physicalexamination• SystematicCOronaryRiskEvaluation(SCORE)• RestingECG

• History• Physicalexamination• RestingECG

Criteria for maximal treadmill exercise testing

• Presenceofalarmingsymptoms• Abnormalphysicalexaminationresults• High-riskSCOREprofile• AbnormalrestingECG

• Symptomssuggestiveofcoronaryarterydisease

• Moderatetohighcardiovascularriskprofile:men>40years,women>50yearswith≥1riskfactor

• Allathletes≥65years

Table. Two approaches to recommendations for physical activity clearance and pre-participation screening in athletes.


larly, the United States and Canada use the Framingham risk score (FRS) in 30- to 74-year-olds with unknown CVD. The FRS is calculated using the patient’s age, blood pressure, total cholesterol level, HDL cholesterol level, smoking history, and knowing whether the patient is taking medica-tion for blood pressure.11 The latest modified FRS also takes into account whether the patient has a history of premature CVD, which results in a doubling of the FRS in those age 30 to 59, and whether CVD is present in a first-degree relative younger than 55 (men) and 65 (women). The patient’s risk is categorized as either low (0% to 9%), intermediate (10% to 19%), or high (20% or more). Consensus groups strongly recommend that cardiovascular risk be assessed rou-tinely, with the frequency depending on the presence and severity of risk markers.11 Studies show the greatest improvement in cardiovascular risk occurs when risk profiles are dis-cussed with and given to the patient.11

Psychological stress assessmentPsychological stress has been associ-ated with the development of prema-ture CVD. The INTERHEART study found that psychological stress was the third-highest risk factor for an acute myocardial infarction, rank-ing behind only smoking and ele-vated lipid levels.12 Psychological stress may contribute to CVD risk by activating the sympathetic ner-vous system. Therefore, assessment of patients’ exposure to both repeated acute mental stress and chronic stress may be useful in determining their risk of developing CVD.

Symptoms, family history, and physical examinationThe AHA 14-element guidelines for cardiovascular screening of athletes have been used in young competitive

athletes.5 A meta-analysis examin-ing the utility of family history and physical examination in screening for CVD reported a low sensitivity of 20% for family history and 9% for physical examination.13 Undoubtedly, this leads to high false-positive rates and subsequent physician referrals. In the masters athlete, the effectiveness of family history and physical exam-ination in screening has not been es-tablished, and the sensitivity of these tools in this population is unknown. Given that the primary cause of sud-den cardiac death in athletes older than 35 is coronary artery disease (CAD), it is important to ask about specific symptoms during history taking (e.g., angina, syncope, or pre-syncope during or after exertion; un-usual fatigue; dyspnea; palpitations) and to determine if there is a family history of cardiovascular disease. The physical examination is import-ant for detecting valvular disease and hypertension, which are highly preva-lent in masters athletes.14,15 However, studies have shown cardiovascular physical examination to have high interobserver variability, which limits its usefulness as an initial screening tool.16 Physician availability and con-comitant cost are other barriers.

Resting 12-lead electrocardiogramThe ongoing debate between Europe-an and US sports cardiology experts on whether or not to include a rest-ing 12-lead ECG in pre-participation screening resides in concerns about the sensitivity and specificity of the test and justification for the cost.5 Subclinical cardiac disease such as prior myocardial infarction, left ven-tricular hypertrophy, and fibrosis, as well as many cardiovascular diseases (e.g., arrhythmias, ion channelopa-thies, arrythmogenic right ventricu-lar cardiomyopathy, hypertrophic

cardiomyopathy) are clinically silent and can be detected by ECG before symptom onset.14,15,17,18 Supporters of ECG use in screening maintain that the history and physical examination alone have marginal value in identi-fying those at risk for sudden cardiac death, while other experts maintain the ECG cannot accurately detect flow-limiting coronary artery disease, and yet others recommend exercise treadmill testing to screen for CAD in an asymptomatic population.6

Concerns that screening with an ECG will result in a high false- positive rate when physiologically normal training-related abnormali-ties are considered pathological can be addressed by ensuring the ECG is analyzed by a sports cardiolo-gist and according to the latest cri-teria.17 Training-related ECG pat-terns can be observed in 60% to 80% of athletes and include bradycardia, sinus arrhythmia, first-degree atrio-ventricular block, early repolariza-tion, incomplete right bundle branch block, and voltage criteria for left ventricular hypertrophy.18 These abnormalities can occur as a result of intense physical training over months or years, and should be evaluated with respect to age, gender, ethnicity, level of training/competition, workload of the sport, and aerobic capacity spe-cific to the sport. For example, endur-ance training and sports such as run-ning, cycling, cross-country skiing, and rowing/canoeing are associated with eccentric remodeling (ventricu-lar dilation coupled with increase in ventricular wall thickness), while strength training is associated with concentric remodeling (increased left ventricular wall thickness) and increased systolic and diastolic blood pressure.19 Both forms of cardiac remodeling have been termed “ath-lete’s heart” and can elicit voltage cri-teria for left ventricular hypertrophy



on ECG.18 Individuals with left ven-tricular hypertrophy on 12-lead ECG do not require follow-up unless the pattern of hypertrophy is accompa-nied by other non-voltage criteria or they have other risk factors sugges-tive of CVD (e.g., long-standing high blood pressure).18

Exercise treadmill testWith its proven ability to predict ar-rhythmias and flow-limiting CAD, the exercise treadmill test has been proposed as a prognostic tool for stratifying risk for sudden cardiac death because it can be used to assess the degree of ST segment depres-sion, hypotensive blood pressure re-sponse, hypertensive blood pressure response, complex ventricular ectopy, and reduced exercise capacity. The Framingham Offspring Cohort study examined subjects with no history of CAD and discovered that failure to reach target heart rate and exer-cise tolerance (METs achieved), were strong predictors of CAD risk in men and women after adjustment of their cardiovascular risk score.20 Mora and colleagues emphasized the utility of stratifying risk for female participants using the exercise treadmill test, dem-onstrating that ST segment response did not predict future risk for CAD events, whereas low exercise capacity and low heart rate recovery after ex-ercise were independent predictors of death from CAD (RR 3.52) and all-cause mortality (RR 2.11).21

Unfortunately, the exercise tread-mill test has been criticized for having a high rate of false-positives in detect-ing CAD in asymptomatic patients with low likelihood of the disease. In males, however, the predictive value improves as the number of cardiovas-cular risk factors increases. For ex-ample, the age-adjusted relative risk of an abnormal exercise test for CAD death was 21 in those with no risk fac-

tors, 27 in those with one risk factor, 54 in those with two risk factors, and 80 in those with three or more risk factors.22 A truly positive exercise treadmill test requires the presence of a flow-limiting coronary lesion, whereas most acute coronary events evolve from a vulnerable plaque rup-ture at points of mild to moderate ste-nosis and are less likely to be detected on such a test.6 In athletes who have a high fitness level (maximal exercise tolerance greater than 10 METs) and a moderate to high risk of CVD, dis-ease and associated symptoms can be masked on an exercise treadmill test, suggesting that imaging tests should be considered in the event of an exer-cise treadmill test without significant findings.23

Other screening optionsCardiovascular imaging as a first-line option in screening may not be appropriate because of concerns about cost-effectiveness, accessibil-ity, and radiation exposure. How-ever, improvements in cardiovascu-lar imaging technology coupled with improvements in therapeutic options for CVD have led to greater interest in cardiovascular imaging options for pre-participation screening.23

EchocardiogramMany privately funded professional organizations such as the Internation-al Federation of Association Football, the International Cycling Union, and the US National Basketball Associa-tion include echocardiography as part of first-line screening, whereas scien-tific associations such as the Europe-an Society of Cardiology (ESC) and the American Heart Association do not include echocardiography in their recommended screening processes.

Echocardiography is relatively inexpensive, accessible, and unlikely to cause direct adverse effects. It can

detect disorders not always evident on an ECG, such as coronary anomalies, proximal aortic dilation, bicuspid aor-tic valve, mitral valve prolapse, some cardiomyopathies, and other forms of left ventricular dysfunction, mak-ing it a logical modality for pre-par-ticipation screening.23 However, dis-criminating between physiological and pathological cardiomyopathies in a high-level athlete can be diffi-cult, and use of echocardiograms may inappropriately exclude athletes from competition or fail to reveal patho-logical disease with potential for sudden cardiac death.23 Aagaard and colleagues included echocardiogra-phy along with a personal symptoms questionnaire, physical examina-tion, and ECG when screening male endurance runners and confirmed that the echocardiograms did not reveal any disease that would place the ath-lete at risk for sudden cardiac death beyond the disease discovered using the ECG, physical examination, and personal symptoms questionnaire.14 The echocardiogram could, however, play a prognostic role in identifying age-associated, subclinical CVD24 and potentially permit stratification of risk for atrial fibrillation.25

Cardiac computed tomography and coronary artery calcium scoringCurrently, cardiac computed tomog-raphy (CCT) and coronary artery calcium scoring (CACS) are not recommended for pre-participation screening, but consensus groups sup-port their use in asymptomatic indi-viduals with intermediate (10% to 20%) or low cardiovascular risk (less than 10%) with a positive family his-tory for premature CAD.11

CCT is a highly sensitive test (99%; 95% credible interval 97% to 99%) for detecting clinical and sub-clinical CAD (less than 50% stenosis),



with a very high negative predictive value (median 100%, range 86% to 100%).26 Although not recommend-ed for use in low-risk athletes (e.g., marathon runners) evidence shows CCT can play a role in detecting low to moderate stenosis in an active, fit, asymptomatic athlete.27 In one study, CCT detected mild to moderate CAD in approximately 50% of male mara-thon runners, while the exercise tread-mill test failed to detect any CAD in these same runners.27 Both CCT and CACS have prognostic value over routine risk factors for predicting car-diac events, which could be benefi-cial in stratifying and managing risk in categories above 10% by altering treatment decision making (e.g., iden-tifying those suitable for lipid treat-ment).11 Additionally, the CACS may alter individual lifestyle behaviors and ultimately lower event rates with-out incurring significant downstream medical costs.28 While radiation ex-posure has been posed as a limitation, new technology has substantially re-duced exposure, with a mean effective radiation dose of 0.30 mSv for CACS, which is approximately one-sixth of the radiation we are exposed to an-nually in Canada, and a dose of 1.26 mSv for CCT.27 Larger-scale studies are needed to determine if the use of CCT or CACS leads to reductions in morbidity and mortality before either can be included as a screening tool.

Cardiac magnetic resonance imagingCardiac magnetic resonance (CMR) imaging is the most comprehen-sive imaging modality for excluding pathology and is the gold standard for examining cardiac function in patients and athletes.23 It can distin-guish between athlete’s heart, dilated cardiomyopathy, and mild forms of hypertrophic cardiomyopathy.29 As well, CMR has potential prognostic

value in the detection of subclinical myocardial fibrosis, which is a con-cern in chronic endurance exercis-ers.30 However, because of limited availability, high cost, and the low pre-test probability of cardiac path-ology in the athlete population, this

test is less suitable for broad-based screening.23,29 For athletes with an ab-normal ECG result, especially when a cardiomyopathy, a coronary anom-aly, or myocarditis is suspected, CMR plays a crucial role in diagnosis.23

ConclusionsThe risk of adverse cardiovascular events during exercise increases with age because of the greater preva-lence of atherosclerotic disease in those older than 35. More evidence is needed to determine the best strat-egies to mitigate risk. In addition to pre-participation screening, strategies might include educating masters ath-letes to exercise safely, to promptly report new and unusual symptoms for evaluation, and to consider preven-tive health habits (e.g., monitor blood pressure and lipid levels, maintain healthy body weight). Other strategies might include modifying exercise for high-risk individuals, ensuring emer-gency procedures are in place, and installing automated external defibril-lators in all sporting venues.

Current protocols used around the world have yet to be systematically and extensively evaluated. Further-more, the risk characteristics of Can-ada’s unique, heterogeneous popula-tion have not been established. Before Canadian recommendations can be

developed, a better understanding of CVD prevalence and more data regarding the effectiveness of pro-posed screening procedures will be needed.

Competing interests

None declared.

References

1. Warburton DE, Nicol C, Bredin SS. Health

benefits of physical activity: The evidence.

CMAJ 2006;174:801-809.

2. Siscovick DS, Weiss NS, Fletcher RH, et

al. The incidence of primary cardiac arrest

during vigorous exercise. N Engl J Med

1984;311:874-877.

3. Albert CM, Mittleman MA, Chae CU, et al.

Triggering of sudden death from cardiac

causes by vigorous exertion. N Engl J Med

2000;343:1355-1361.

4. Marijon E, Tafflet M, Celermajer DS, et al.

Sports-related sudden death in the gen-

eral population. Circulation 2011;124:672-

681.

5. Maron BJ, Friedman RA, Kligfield P, et al.

Assessment of the 12-lead electrocardio-

gram as a screening test for detection of


The risk of adverse cardiovascular

events during exercise increases

with age because of the greater

prevalence of atherosclerotic

disease in those older than 35.



cardiovascular disease in healthy general

populations of young people (12-25 years

of age): A scientific statement from the

American Heart Association and the

American College of Cardiology. J Am Coll

Cardiol 2014;64:1479-1514.

6. Maron BJ, Van Camp SP, Elosua R, et al.

Recommendations for preparticipation

screening and the assessment of cardio-

vascular disease in masters athletes: An

advisory for healthcare professionals from

the working groups of the World Heart

Federation, the International Federation of

Sports Medicine, and the American Heart

Association Committee on Exercise, Car-

diac Rehabilitation, and Prevention. Circu-

lation 2001;103:327-334.

7. Bredin SS, Gledhill N, Jamnik VK, et al.

PAR-Q+ and ePARmed-x+: New risk strat-

ification and physical activity clearance

strategy for physicians and patients alike.

Can Fam Physician 2013;59:273-277.

8. Warburton DER, Bredin SSD, Jamnik V, et

al. Consensus on evidence-based pre-

participation screening and risk stratifica-

tion. Ann Rev GerontolGeriatr 2016;36:

53-102.

9. Borjesson M, Urhausen A, Kouidi E, et al.

Cardiovascular evaluation of middle-aged/

senior individuals engaged in leisure-time

sport activities: Position stand from the

sections of exercise physiology and

sports cardiology of the European Asso-

ciation of Cardiovascular Prevention and

Rehabilitation. Eur J Cardiovasc Prev Re-

habil 2011;18:446-458.

10. Herbert DL, Eickhoff-Shemek JM. New

standards statements: Legal consider-

ations for the fitness industry. ACSMs

Health Fit J 2010;14:31-33.

11. Anderson TJ, Gregoire J, Hegele RA, et al.

2012 update of the Canadian Cardiovas-

cular Society guidelines for the diagnosis

and treatment of dyslipidemia for the pre-

vention of cardiovascular disease in the

adult. Can J Cardiol 2013;29:151-167.

12. Yusuf S, Hawken S, Ounpuu S, et al. Ef-

fect of potentially modifiable risk factors

associated with myocardial infarction in

52 countries (the INTERHEART study):

Case-control study. Lancet 2004;364

(9438):937-952.

13. Harmon KG, Zigman M, Drezner JA. The

effectiveness of screening history, physi-

cal exam, and ECG to detect potentially

lethal cardiac disorders in athletes: A sys-

tematic review/meta-analysis. J Electro-

cardiol 2015;48:329-338.

14. Aagaard P, Sahlen A, Bergfeldt L, et al.

Preparticipation evaluation of novice, mid-

dle-age, long-distance runners. Med Sci

Sports Exerc 2013;45:130-137.

15. Menafoglio A, Di Valentino M, Porretta AP,

et al. Cardiovascular evaluation of middle-

aged individuals engaged in high-intensity

sport activities: Implications for workload,

yield and economic costs. Br J Sports

Med 2014.

16. Mangione S, Nieman LZ. Cardiac auscul-

tatory skills of internal medicine and fam-

ily practice trainees. A comparison of diag-

nostic proficiency. JAMA 1997;278:

717-722.

17. Drezner JA, DiFiori JP, Fischbach P, et al.

Electrocardiographic interpretation in ath-

letes: The ‘Seattle criteria’. Br J Sports

Med 2013;47:122.

18. Drezner JA, Fischbach P, Froelicher V, et

al. Normal electrocardiographic findings:

Recognising physiological adaptations in

athletes. Br J Sports Med 2013;47:125-

136.

19. Mihl C, Dassen WR, Kuipers H. Cardiac

remodelling: Concentric versus eccentric

hypertrophy in strength and endurance

athletes. Neth Heart J 2008;16:129-133.

20. Balady GJ, Larson MG, Vasan RS, et al.

Usefulness of exercise testing in the pre-

diction of coronary disease risk among

asymptomatic persons as a function of

the Framingham risk score. Circulation

2004;110:1920-1925.

21. Mora S, Redberg RF, Cui Y, et al. Ability of

exercise testing to predict cardiovascular

and all-cause death in asymptomatic

women: A 20-year follow-up of the lipid

research clinics prevalence study. JAMA

2003;290:1600-1607.

22. Gibbons LW, Mitchell TL, Wei M, et al.

Maximal exercise test as a predictor of risk

for mortality from coronary heart disease

in asymptomatic men. Am J Cardiol 2000;

86:53-58.

23. La Gerche A, Baggish AL, Knuuti J, et al.

Cardiac imaging and stress testing

asymptomatic athletes to identify those

at risk of sudden cardiac death. JACC

Cardiovasc Imaging 2013;6:993-1007.

24. Crendal E, Dutheil F, Naughton G, et al.

Increased myocardial dysfunction, dys-

synchrony, and epicardial fat across the

lifespan in healthy males. BMC Cardio-

vasc Disord 2014;14:95.

25. Mont L, Tamborero D, Elosua R, et al.

Physical activity, height, and left atrial size

are independent risk factors for lone atrial

fibrillation in middle-aged healthy individu-

als. Europace 2008;10:15-20.

26. Mowatt G, Cummins E, Waugh N, et al.

Systematic review of the clinical effective-

ness and cost-effectiveness of 64-slice or

higher computed tomography angiogra-

phy as an alternative to invasive coronary

angiography in the investigation of coro-

nary artery disease. Health Technolog

Assess 2008;12:iii-iv,ix-143.

27. Tsiflikas I, Thomas C, Fallmann C, et al.

Prevalence of subclinical coronary artery

disease in middle-aged, male marathon

runners detected by cardiac ct. Rofo

2015;187:561-568.

28. Rozanski A, Gransar H, Shaw LJ, et al. Im-

pact of coronary artery calcium scanning

on coronary risk factors and downstream

testing: A prospective randomized trial.

J Am Coll Cardiol 2011;57:1622-1632.

29. Mangold S, Kramer U, Franzen E, et al.

Detection of cardiovascular disease in

elite athletes using cardiac magnetic reso-

nance imaging. Rofo 2013;185:1167-

1174.

30. Wilson M, O’Hanlon R, Prasad S, et al.

Diverse patterns of myocardial fibrosis in

lifelong, veteran endurance athletes. J

Appl Phsiol (1985) 2011;110:1622-1626.

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Cardiovascular pre-participation screening and risk ...€¦ · ters athlete. R outine physical activity is associated with improved health and well-being and a reduction in adverse